1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 13 Male Genitalia and Hernias

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy and Physiology The penis –The shaft of the penis is formed by three columns of vascular erectile tissue: oThe corpus spongiosum, containing the urethra oThe two corpora cavernosa –The corpus spongiosum forms the bulb of the penis, ending in the cone-shaped glans with its expanded base, or corona

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy and Physiology (cont.) The penis –In uncircumcised men, the glans is covered by a loose, hood-like fold of skin called the prepuce, or foreskin, where smegma, or secretions of the glans, may collect –The urethra opens into the vertical, slit-like urethral meatus

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy and Physiology (cont.) The testes –The testes are ovoid, somewhat rubbery structures approximately 4.5 cm long –The left testis usually lies somewhat lower than the right –The testes produce spermatozoa and testosterone

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy and Physiology (cont.) The testes (cont.) –The scrotum is a loose, wrinkled pouch divided into two compartments, each containing a testis –Covering the testis, except posteriorly, is the serous membrane of the tunica vaginalis –On the posterolateral surface of each testis is the softer comma-shaped epididymis; the epididymis provides a reservoir for storage, maturation, and transport of sperm

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy and Physiology (cont.) The lower genitourinary tract –The vas deferens, a cordlike structure, begins at the tail of the epididymis –It ascends within the scrotal sac (as the spermatic cord) and passes through the external inguinal ring on its way to the abdomen and pelvis –Behind the bladder, it is joined by the duct from the seminal vesicle and enters the urethra within the prostate gland

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy and Physiology (cont.)

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy and Physiology (cont.) The groin –The basic landmarks of the groin are the anterior superior iliac spine, the pubic tubercle, and the inguinal ligament –The inguinal canal, which lies above and parallel to the inguinal ligament, forms a tunnel for the vas deferens –The exterior opening of the tunnel is the external inguinal ring; the internal opening of the canal is the internal inguinal ring

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy and Physiology (cont.) The groin –When loops of bowel force their way through weak areas of the inguinal canal, they produce inguinal hernias –Another potential route for a herniating mass is the femoral canal; femoral hernias protrude here

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Tips for Taking the Sexual History Explain why you are taking the sexual history This information is highly personal, so encourage the patient to be open and direct Assure the patient that you gather a sexual history on all patients Affirm that your conversation is confidential

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health History Sexual preference and sexual response questions –Begin with a general question, such as “How is sexual function for you?” –If there is a problem, direct questions help to assess each phase of the sexual response. oHave you maintained interest in sex? (desire) oCan you achieve and maintain an erection? (arousal) oAbout how long does intercourse last? (orgasm and ejaculation)

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health History (cont.) Symptoms of infection questions –Is there any discharge from the penis, dripping, or staining of underwear? If so, how much and what is its color and consistency? –Any associated fever, chills, or rash? –Any sores or growths on the penis? –Any pain or swelling in the scrotum? –Any history of risk factors for sexually transmitted disease? (promiscuity, homosexuality, illicit drug use)

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Promotion and Counseling Prevention of STDs and HIV Testicular self-examination

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination It may be reassuring to explain each step of the examination so the patient knows what to expect Occasionally, male patients have erections during the examination; if this happens, you should explain that this is a normal response Many will feel uneasy about examining a man’s genitalia

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination (cont.) A good genital examination may be done with the patient either standing or supine When checking for hernias, the patient should stand and the examiner should sit on a chair or stool

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination: Inspection of the Penis Skin –Check the skin around the base of the penis for excoriations or inflammation Prepuce (if present, ask the patient to retract) –Smegma, a cheesy, whitish material, may accumulate normally under the foreskin Glans – look for ulcers, scars, nodules, or signs of inflammation –Note the location of the urethral meatus –Compress the glans gently between your index finger above and thumb below to open the urethral meatus and allow inspection for discharge (normally there is none)

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination (cont.) The penis –If the patient has reported a discharge that you are unable to see, ask him to milk the shaft of the penis from its base to the glans. This maneuver may bring some discharge to the urethral meatus for appropriate examination. –Palpate any abnormality of the penis, noting tenderness or induration –Palpate the shaft of the penis, noting any induration

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination: Palpation of the Penis Palpate any abnormality Note tenderness or induration

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination: Scrotum and Its Contents Scrotum, testes, epididymis, and spermatic cord –Inspection oSkin – lift the scrotum to view its posterior surface oScrotal contours – note swelling, lumps, veins –Palpation oEach testis and epididymis – note size, shape, consistency, and tenderness; feel for any nodules  Epididymis is a soft, nodular, cordlike structure at the back of the testicle oEach spermatic cord – note nodules or swelling

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A 21-year-old male presents complaining of a “nodule” on the back of his left testicle found during testicular self-examination. On examination, you find both testicles to be of normal size, shape, and consistency. On the back of the left testicle in the area of the “nodule,” you find a soft, nodular, tubelike structure with no areas of abnormal tenderness. Your most likely diagnosis is: a.Acute epididymitis b.Cyst of the epididymis c.Normal epididymis d.Carcinoma of the epididymis

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer c.Normal epididymis The epididymis is located on the superior, posterior surface of each testicle. It feels nodular, soft, and cordlike and should not be confused with an abnormal lump.

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination (cont.) Hernias –Inspection oSit comfortably in front of the standing patient  Note any areas of bulging or asymmetry  Ask the patient to strain and bear down, making it easier to detect any hernias –Palpation oInguinal and femoral hernias

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination (cont.) Evaluating a possible scrotal hernia –If a large scrotal mass is found, ask the patient to lie down. If the mass disappears, it is a hernia. –If the mass remains: oListen to the mass with a stethoscope. If bowel sounds are heard, it is a hernia. oShine a strong light from behind the scrotum through the mass (transillumination). If a red glow is observed, it is probably not a hernia.

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following statements about hernias is true? a.Indirect inguinal hernias are the most common form of hernia b.Femoral hernias are the least common form and are more common in women c.Direct inguinal hernias are more common in men over age 40 d.Indirect inguinal hernias originate above the inguinal ligament near its midpoint e.All of the above

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer e.All of the above Indirect inguinal hernias are the most common form of hernia Femoral hernias are the least common form and are more common in women Direct inguinal hernias are more common in men over age 40 Indirect inguinal hernias originate above the inguinal ligament near its midpoint